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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KDHL-AZNR7D

FACILITY NAME English Bluff		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0920120
FACILITY ADDRESS 4836 13th Ave			FACILITY PHONE (604) 943-5173
CITY Delta	POSTAL CODE V4M 2B8		MANAGER Kulvir Sidhu

INSPECTION DATE June 12, 2018	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 3.5
ARRIVAL 09:45 AM	DEPARTURE 01:15 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection. The following areas were reviewed: · Licensing · Physical Facility · Staffing · Polices & Procedures · Care & Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation. Visit the CCFL website at www.fraserhealth.ca/residentialcare for: · Additional resources and · Links to the Legislation (CCALA & RCR)

Contraventions

Previous Inspection -

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Review of June Charting binder for one person in care, 2 of 12 days missed documenting shift report. Discussion with the manager confirmed the expectation is to complete documentation at each shift. The expectation is information is entered, even when there is no activity in the specific area. Corrective Action(s): Ensure staff follow policies and procedures. Date to be Corrected: July 13, 2018

Comments

In review of the laundry space, discussion with the manager and coordinator regarding assessing when a slip mat may be required. Review of consents in place, it is recommended that any consents relevant to legislative requirements are maintained on site or accessible when requested.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Jul 13, 2018

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